The form is used to collect information from patients about when and where they received their latest preventive services.
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There is a one-page form for female patients and a one-page form for male patients.
Download the preventive services patient data collection form (pdf) developed by the Oklahoma Foundation for Medical Quality for adaptation and use in your facility.
Note: View our database providing more than 100 reports that link to free, downloadable and adaptable tools for use in surgery centers, hospitals and other organizations by clicking here.
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